Autism Care Demonstration Update: CPT® 97151 Clarification

Friday, November 12, 2021

On Aug. 1, 2021, TRICARE adopted use of Current Procedural Terminology (CPT®) 97151 in place of T1023 for outcome measures approved on and after Aug. 1. Separately, CPT 97151 is also used when billing for applied behavior analysis assessments. Due to the difficulty in distinguishing whether CPT 97151 is being billed as an outcome measure or initial assessment/reassessment service, we’ve updated our claims systems to accept modifier ‘99’ when billing CPT 97151 for outcome measures. This will help expedite claims processing for Autism Care Demonstration claims. Effective immediately:

CPT 97151 with modifier 99: Use for outcome measures authorized as of Aug. 1
CPT 97151 without modifier 99: Use for initial assessments and reassessments

Modifiers are entered into item number 24D on the CMS 1500 professional claim form, or the HIPAA 837 Professional Electronic format, Loop ID 2400, Segment/Data Element SV101 (2-6).

As a reminder, units authorized for CPT 97151 are as follows:

97151 Behavior Identification Assessment:
- Initial assessments: Approved for 32 units per authorization period.
  Reassessments: Approved for 24 units per authorization period.
- Approved units include the administration, scoring and analysis of PDDBI.

97151 Outcome Measures
- One unit per measure for each additional outcome measure (Vineland Adaptive Behavior Scales, 3rd Edition (Vineland-3), Social Responsiveness Scale, Second Edition (SRS-2), and Parenting Stress Index, Fourth Edition (PSI-4), Short Form or Stress Index for Parents of Adolescents (SIPA).

Please review TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.6 and our ACD Billing page for complete details on TRICARE-approved ABS CPT codes.